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Research Report

Gait Training Combining Partial


Body-Weight Support, a Treadmill,
and Functional Electrical Stimulation:
Effects on Poststroke Gait
Ana RR Lindquist, Christiane L Prado, Ricardo ML Barros, Rosana Mattioli,
Paula H Lobo da Costa, Tania F Salvini
ARR Lindquist, PT, PhD, is Profes-
sor, Department of Physical Ther-
apy, Federal University of Rio
Background and Purpose
Grande do Norte, Brazil. Treadmill training with harness support is a promising, task-oriented approach to
CL Prado, PT, MS, Unit of Skeletal
restoring locomotor function in people with poststroke hemiparesis. Although the
Muscle Plasticity, Department of combined use of functional electrical stimulation (FES) and treadmill training with
Physical Therapy, Federal Univer- body-weight support (BWS) has been studied before, this combined intervention was
sity of São Carlos, Brazil. compared with the Bobath approach as opposed to BWS alone. The purpose of this
RML Barros, PhD, is Associate Pro- study was to evaluate the effects of the combined use of FES and treadmill training
fessor, Laboratory of Instrumenta- with BWS on walking functions and voluntary limb control in people with chronic
tion for Biomechanics, College of hemiparesis.
Physical Education, Campinas
State University, Brazil.
Subjects
R Mattioli, PT, PhD, is Professor, Eight people who were ambulatory after chronic stroke were evaluated.
Laboratory of Neuroscience, De-
partment of Physical Therapy,
Federal University of São Carlos. Methods
PH Lobo da Costa, PhD, is Profes-
An A1-B-A2 single-case study design was applied. Phases A1 and A2 included 3 weeks
sor, Department of Physical Edu- of gait training on a treadmill with BWS, and phase B included 3 weeks of treadmill
cation and Kinesiology, Federal training plus FES applied to the peroneal nerve. The Stroke Rehabilitation Assessment
University of São Carlos. of Movement was used to assess motor recovery, and a videography analysis was used
TF Salvini, PhD, Unit of Skeletal to assess gait parameters.
Muscle Plasticity, Department of
Physical Therapy, Federal Univer- Results
sity of São Carlos, Brazil. Address
all correspondence to Dr Salvini
An improvement (from 54.9% to 71.0%) in motor function was found during phase
at: tania@power.ufscar.br. B. The spatial and temporal variables cycle duration, stance duration, and cadence as
well as cycle length symmetry showed improvements when phase B was compared
[Lindquist ARR, Prado CL, Barros
RML, et al. Gait training combin-
with phases A1 and A2.
ing partial body-weight support, a
treadmill, and functional electrical Discussion and Conclusions
stimulation: effects on poststroke The combined use of FES and treadmill training with BWS led to an improvement in
gait. Phys Ther. 2007;87:
1144 –1154.]
motor recovery and seemed to improve the gait pattern of subjects with hemiparesis,
indicating the utility of this combination method during gait rehabilitation. In addi-
© 2007 American Physical Therapy tion, this single-case series showed that this alternative method of gait training—
Association
treadmill training with BWS and FES—may decrease the number of people required
to carry out the training.

Post a Rapid Response or


find The Bottom Line:
www.ptjournal.org

1144 f Physical Therapy Volume 87 Number 9 September 2007


Effects of Gait Training on Poststroke Gait

G
ait restoration is a major goal changes in the nervous system that trical signals to activate peripheral
in poststroke neurological re- correlate with improvements in mo- nerves and control functional move-
habilitation. For this reason, tor behavior. Animal and human ments. This technique makes use of
the recovery of independent walking work in locomotor recovery is par- afferent feedback during contrac-
is important in rehabilitation studies. ticularly relevant to the neurophysi- tion, a process that, with a patient’s
Gait training on a treadmill with ological rationale for step training on help, may maximize motor relearn-
body-weight support (BWS) has re- a treadmill, given that it specifically ing during active repetitive move-
ceived special attention. It consists addresses how neuroplasticity is in- ment training.18,19
of a suspension system to which a duced by repetitive locomotor activ-
patient is connected so that weight ity that attempts to optimize the sen- The combined use of FES and partial
shifting, balance, and stepping can sorimotor experience of walking at BWS training was previously report-
be controlled; walking is facilitated the spinal and supraspinal levels.11–13 ed.20 –23 Hesse et al20 investigated the
by a treadmill.1 Several studies1–3 use of multichannel electrical stimu-
with promising outcomes have People with hemiparesis often dis- lation combined with treadmill train-
shown the feasibility of supported play abnormal gait patterns, such as ing and partial BWS for subjects with
treadmill ambulation training in pa- equinovarus (excessive plantar flex- hemiplegia. After the training pro-
tients with stroke, but whether it is ion and inversion) or foot drop (ex- gram, improvements were seen in
superior to other gait therapies is still cessive plantar flexion), in which gait parameters such as speed, stride
under dispute.4 According to Visin- selective control impairments are length, and cadence. That study had
tin and Barbeau,2 partial unloading of particularly prominent in the feet. important implications for walking
the lower extremities (40%) in sub- During walking, a person’s big toe in subjects with hemiplegia and
jects with hemiparesis results in a and outer foot margin rub against the showed that the combined use of
straighter trunk and knee alignment ground, thus putting the person at FES and partial BWS training im-
during the loading phase, a decrease risk of sustaining sprains and other proved their gait pattern. However,
in double-limb support time, and an ankle injuries.14 To minimize these that study was carried out with sub-
increase in single-limb support time, patterns, electrical stimulation to jects in both chronic and acute post-
stride length, and speed. On the ba- correct spastic foot drop in hemiple- stroke phases, when spontaneous
sis of research with quadrupeds, in- gia was first applied by Liberson and functional recovery is to be expect-
direct evidence suggests that this coworkers in 1961.15 Surface elec- ed.24 In addition, FES was applied to
rehabilitation strategy apparently trodes were applied to the peroneal the peroneal nerve and to the quad-
drives spinal motor programs nerve at the fibular head, and a stim- riceps femoris, biceps femoris, and
through proprioceptive inputs and ulator worn around the waist was pelvic stabilization muscles, accord-
modulates spinal rhythm genera- controlled by a switch in the heel of ing to the needs of each individual.
tors.5,6 Furthermore, it may lead to the shoe worn on the affected limb. The combined intervention with FES
an improvement in sensory inputs When a subject raised the heel to and partial BWS training was com-
and better functional motor take a step, the stimulator was acti- pared with conventional physical
reorganization.7,8 vated. Stimulation stopped when the therapy (Bobath approach) as op-
heel came in contact with the posed to partial BWS training alone.
According to the specificity of learn- ground again. This system, known as
ing hypothesis,9 optimal motor learn- the peroneal stimulator, produces In a study of the combined use of FES
ing occurs when performance dur- foot dorsiflexion and eversion during and partial BWS training, Daly and
ing practice is well matched to that the swing phase of gait. Other stud- Ruff22 used intramuscular electrodes
required for retention or transfer- ies16,17 have shown that peroneal to stimulate lower-limb muscles, but
ence conditions. According to stimulation to prevent foot drop in no comparisons were made between
Schmidt and Lee,10 motor learning people with stroke improves walk- combined therapies and one training
reflects a neural specificity of prac- ing, because it can provide critical method alone. We found no pub-
tice because it involves the integra- practice of close-to-normal move- lished studies comparing the influ-
tion of motor information and sen- ments by electrically inducing mus- ence of a combination of FES and
sory information available during cle contraction and coordinated partial BWS training with the influ-
practice. The specificity of learning movements not volitionally possible. ence of partial BWS training alone on
hypothesis is consistent with ad- the gait pattern of subjects with
vances in neurorecovery and neuro- Functional electrical stimulation chronic hemiparetic stroke.
plasticity, which have shown that (FES), based on the concepts de-
task-specific activity results in scribed by Liberson et al,15 uses elec-

September 2007 Volume 87 Number 9 Physical Therapy f 1145


Effects of Gait Training on Poststroke Gait

The aims of this study were: (1) to ple. At level 1, people need the con- poststroke ability. Two independent
compare the effects of the combined tinuous support of 1 person to help physical therapists assessed outcome
use of FES and partial BWS training them carry their weight and maintain measurements; the intraclass correla-
with the effects of partial BWS train- their balance. At level 2, people are tion coefficient for interrater reliabil-
ing alone on walking functions and dependent on the continuous or in- ity for the STREAM was .93.
voluntary limb control and (2) to in- termittent support of 1 person to
vestigate whether the use of FES in help with balance or coordination. Gait Analysis
conjunction with partial BWS train- At level 3, people need only verbal The over-ground walking variables
ing provided any additional benefit supervision. At level 4, help is re- were measured as the subjects
to subjects with chronic hemipare- quired on stairs and uneven surfaces. walked along a 6-m walkway. Accel-
sis. We hypothesized that the com- Level 5 describes people who can eration and deceleration compo-
bined use of FES and partial BWS walk independently in any given nents were not included in the data.
training would provide greater im- place. The subjects were assessed before
provement in gait outcomes than and 1 day after each treatment pe-
partial BWS training alone. The gait The following inclusion criteria were riod. Four subjects used a single-
outcomes analyzed were motor func- considered in the selection of the point cane during each assessment.
tion and gait parameters (stride subjects: an interval of greater than 6 The subjects walked at their self-
length, cycle duration, gait speed, months after stroke; spasticity classi- selected speed along the walkway 3
stance duration, swing duration, ca- fied at level 2 or 3 according to the times, and the 3 trials were recorded
dence, cycle length symmetry, swing Modified Ashworth Spasticity Scale as definitive data for the gait param-
duration symmetry, and stance dura- (because this should allow people to eters. These values were used to
tion symmetry). walk with or without the help of a compute the following parameters:
cane or another person); over- stride length (in meters), cycle dura-
Method ground walking classified at level 2 tion (in seconds), gait speed (in
Subjects or 3 according to the Functional Am- meters per second), stance duration
Eight people who were ambulatory bulation Category; no clinical signs (in seconds), swing duration (in
after chronic stroke (2 women and of heart failure (New York Heart As- seconds), cadence (in steps per
6 men, age [X⫾SD]⫽56.6⫾10.26 sociation grade 0),27 arrhythmia, or minute), cycle length symmetry,
years, stroke interval⫽17.3⫾10.9 angina pectoris; no other orthopedic swing duration symmetry, and
months) took part in the study. Two or neurological diseases impairing stance duration symmetry.
subjects had right-side hemiparesis, gait; and no severe cognitive or com-
and 6 subjects had left-side hemipa- munication impairments. The gait analysis system included 5
resis, which was caused by right or digital video cameras (JVC Profes-
left supratentorial ischemic stroke Motor Function sional Dv Camcorder Gy-DV300*)
(n⫽6) or intracerebral hemorrhage Motor recovery was assessed before placed to provide lateral, anterior,
(n⫽2). All participants signed an in- and 1 day after each treatment pe- and posterior views of the subjects.
formed consent form. riod with the Stroke Rehabilitation Camera calibration was based on a
Assessment of Movement (STREAM), direct linear transformation method,
Spasticity (hypertonicity) was exam- which is an instrument for monitor- and the calibration parameters were
ined with the Modified Ashworth ing basic mobility and voluntary used for a 3-dimensional reconstruc-
Spasticity Scale for lower-limb mus- movement of the limbs.28 The tion of the markers. Before the sub-
cles. Levels ranged from 0 to 5, STREAM is a 25-item scale that uses 4 jects walked along the walkway,
where 0 represents no increase at all points for some items and 2 points retroreflective spherical markers
in muscle tone (velocity-dependent for others. The maximum score is (diameter⫽10 mm) were attached to
resistance to stretch) and 5 indicates 60; higher scores indicate better the big toe and heel of each foot. The
that the joint was rigid in flexion or function. According to Ahmed et kinematic analysis uncertainty re-
extension.25 Over-ground walking al,29 STREAM shows good measure- lated to the spatial measurements
was assessed with the Functional ment properties. In that study, the (eg, stride length) was ⫾0.002 m.
Ambulation Category test,26 which is STREAM was compared with the Given the frame rate used, the uncer-
based on a walking distance of 10 m. Berg Balance Scale, the Barthel In- tainty related to the temporal mea-
The test includes 6 levels of person- dex, and the Timed “Up & Go” Test. surements was ⫾0.0167 second
nel support needed for gait. Level 0 The results showed that the STREAM
describes people unable to walk or was as accurate as the other scales in * JVC Company of America, 1700 Valley Rd,
requiring the help of 2 or more peo- predicting gait speed and functional Wayne, NJ 07470.

1146 f Physical Therapy Volume 87 Number 9 September 2007


Effects of Gait Training on Poststroke Gait

Table 1.
Gait Ability of Each Subjecta

Subject MA BWS (%) Speed (m/s) FES Time (min)


No.
PT A1 B A2 PT A1 B A2 PT A1 B A2 PT A1 B A2
1 Yes Yes No No 30 25 25 25 0.2 0.6 1 1 20 35 45 45
2 Yes No No No 30 25 25 25 0.2 0.4 0.8 0.8 30 45 45 45
3 No No No No 30 16 0 0 0.6 1.1 2 2 35 45 45 45
4 No No No No 30 25 15 15 0.6 1 1.4 1.4 35 45 45 45
5 No No No No 30 30 20 20 0.3 1 1.1 1.1 30 40 45 45
6 Yes Yes No No 30 30 25 25 0.6 1.1 1.5 1.5 35 40 45 45
7 No No No No 30 20 0 0 0.6 1.3 1.5 1.5 35 40 45 45
8 Yes Yes Yes Yes 30 30 30 30 0.3 0.3 0.3 0.3 20 35 45 45
a
A1⫽data obtained after phase A1, A2⫽data obtained after phase A2, B⫽data obtained after phase B, BWS⫽body-weight support, FES⫽functional electrical
stimulation, MA⫽manual assistance, PT⫽pretraining data, speed⫽gait speed at which the subjects were trained.

(1/60 second). Both variability mea- Two trainers were involved in the speed was increased according to
surements were about 10 times therapy of all of the subjects. During the gait quality of each subject.
smaller than the intrasubject and each session, the therapists decided, When speed was increased and a
intersubject variabilities observed in on the basis of clinical assessment, subject failed to maintain trunk and
the experiments. The camera system when to decrease the BWS for each limb alignment or was unable to per-
collected gait parameters at 60 Hz subject. After 6 sessions, 7 subjects form initial contact properly, speed
with a shutter speed of 1/500 sec- showed reduced BWS (from 30% to was reduced once again. After 9 ses-
ond. A Dvideow System30 was used 25%); at the end of the study, they sions, a mean treadmill speed of 0.9
to process the kinematic parameters. needed about 17% BWS (Tab. 1). m/s (range⫽0.3–1.0 m/s) was
Only 1 subject still needed 30% BWS reached; speed reached 1.2 m/s
Training Protocol at the end of the training period (range⫽0.3–1.5 m/s) at the comple-
A treadmill system similar to that de- (Tab. 1). The subjects were weighed tion of session 27 (Tab. 1).
scribed previously was used in this weekly to determine BWS reloading.
study.31 Harness-secured partici- Subjects could hold onto the hori-
pants walked on a treadmill that was During each training session, the zontal bars attached to the sides of
connected to an overhead suspen- treadmill speed was increased ac- the treadmill for stability. Manual as-
sion system positioned over the cording to the ability of the subjects, sistance, such as paretic limb load-
treadmill (Athletic Speedy 3†). The who were instructed to walk at a ing, knee control, help in hip and
suspension system was an overhead- comfortable speed and encouraged trunk erection, and body weight
motorized pneumatic lift with a dig- to walk as fast as possible while shifting, was given according to indi-
ital readout displaying the amount of maintaining a good gait pattern. In vidual needs. All subjects received
BWS (Challenger 2 MSI-3360‡). other words, they needed to be able verbal cueing during the training. In-
to maintain proper trunk and limb structions about trunk alignment,
Training started with 30% BWS; the alignment and transfer weight onto step length, and knee flexion during
BWS was decreased progressively as the hemiplegic limb. Treadmill the swing phase also were given ac-
the subjects increased their activity speed was adjusted to a comfortable cording to individual requirements.
tolerance and were able to carry the cadence and stride length for each
remaining load on the paretic leg subject. The mean treadmill speed Functional electrical stimulation
throughout stance and swing with- was 0.4 m/s (range⫽0.2– 0.6 m/s) at time (in minutes) was adjusted ac-
out the help of a physical therapist. the beginning of gait training cording to verbal feedback from the
(Tab. 1). At the beginning of each subjects during the 20- to 45-minute

Athletic Indústria e Comércio, Rua Barão de training session, the subjects walked stimulation period (Tab. 1). The sub-
Tefé 326, Joinvile, Santa Catarina, Brazil CEP
89223-350. at the same speed at which they had jects were instructed to say when

Data Weighing Systems, Inc, 2100 Land- stopped in the previous session. This they felt fatigue related to dorsiflex-
meier Rd, Elk Grove, IL 60007.

September 2007 Volume 87 Number 9 Physical Therapy f 1147


Effects of Gait Training on Poststroke Gait

stimulus current to the stimulation


electrodes during the swing phase
(Fig. 1). The stimulation parameters
were symmetrical biphasic square
waves of 150 microseconds, fre-
quency of 25 Hz, and between 60
and 150 V, depending on subject tol-
erance and the level of stimulation
needed to elicit robust dorsiflexion
and foot eversion.

Data Analysis
Descriptive statistics were used to
compare baseline characteristics and
gait scores after phases A1, B, and A2.
An analysis of variance for repeated
measures was performed to compare
the main effects before, during, and
after treatment for the continuous
variables (gait speed, cycle duration,
cadence, cycle length, duration of
swing phase, duration of stance phase,
and symmetry ratio). A post hoc Bon-
ferroni multiple-comparisons test was
used to determine differences be-
tween training phases (baseline and
A1, A1 and B, and B and A2). An alpha
level of 5% was chosen, and GB-STAT
software㛳 was used for statistical
analyses.
Figure 1.
Electrode positions. (A) Electronic stimulator. (B) Stimulation electrode placed at the
motor point of the common peroneal nerve in the area between the popliteal fossa and Results
the head of the fibula. (C) Electrode placed on the anterior tibialis belly. (D) Footswitch Motor Function
located at the heel of the affected foot, inside the shoe. The percentage of motor recovery of
the subjects, determined with the
STREAM, showed an improvement
ion and eversion movements of the asked about their preference regard- in motor function after phase B
stimulated leg. In that situation, FES ing the 2 interventions through (71%) compared with the results ob-
was discontinued for 5 minutes and open-ended questions. tained after phase A1 (56%) (Fig. 2A).
then activated again. As volitional The first assessment, carried out be-
control improved, the FES amplitude A portable stimulator (Electronic fore the treadmill training, showed
was reduced. Treadmill training was Dorsiflexion Stimulator§) was used that the subjects performed
completed after 27 sessions (3 days to stimulate the common peroneal 54.9%⫾21.9% (X⫾SD) of the items
per week for 9 weeks), each session nerve during the swing phase of the proposed by the STREAM, corre-
lasting 45 minutes. gait cycle but was not activated dur- sponding to 33⫾13.2 points out of
ing the stance phase. The stimulator the maximum score of 60 points. Af-
The A1-B-A2 study was applied as fol- was equipped with an electronic ter phase A1, no significant changes
lows: phase A1 included gait training control, sensors, and stimulation were found in the STREAM data; the
with BWS, phase B included gait electrodes. Leads carried the sensor subjects performed 56%⫾21.2% of
training with BWS in combination signals to the electronic control and the activities, corresponding to
with FES, and phase A2 included gait 33.6⫾12.7 points (Fig. 2A). How-
training with BWS. Each of the train- §
Professor Ascendino Reis, 724 Vila Clem-
ing phases lasted 3 weeks. At the end entino–São Paulo, São Paulo, Brazil, CEP 㛳
Dynamic Microsystems Inc, 13003 Bucca-
of gait training, participants were 04027-000. neer Rd, Silver Spring, MD 20904.

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Effects of Gait Training on Poststroke Gait

Figure 2.
Stroke Rehabilitation Assessment of Movement (STREAM). Evaluations of gait variables were performed at the beginning of the study
(1) and after each phase: A1 (2), B (3), and A2 (4). Horizontal bars indicate the between-phase differences. Vertical error bars represent
standard deviations. Asterisks indicate significant differences between measurements (P⬍.01). (A) Mean STREAM scores with time.
(B) Stride length. (C) Cycle duration. (D) Gait speed with time. (E) Cadence.

ever, after phase B, a significant in- flexion in the supine position (4 sub- jects), taking 3 steps backward (5
crease was observed (71%⫾22.6%), jects), hip flexion when seated (7 subjects), taking 3 steps sideways on
corresponding to 42.6⫾13.6 points. subjects), extension of knee when affected side (5 subjects), and alter-
After phase A2, the subjects per- seated (3 subjects), ankle flexion nating feet while walking down 3
formed 72.3%⫾22.7% of the activi- when seated (6 subjects), flexion of stairs (7 subjects). Upper-limb motor
ties, corresponding to 43.4⫾13.6 affected knee with hip extended (3 activities changed slightly in 2 sub-
points; no differences were found subjects), dorsiflexion of affected an- jects. The raw data for the change
between phases B and A2. kle with knee extended (8 subjects), scores are shown in Table 2. When
rising to a standing position from a asked about their preference for
The following items changed with seated position (7 subjects), placing walking on the treadmill with BWS
the training period: hip and knee of affected foot onto first step (8 sub- combined with FES or without FES,

September 2007 Volume 87 Number 9 Physical Therapy f 1149


Effects of Gait Training on Poststroke Gait

Table 2.
Stroke Rehabilitation Assessment of Movement Scoresa

Subject Pretraining Scores Scores After Phase A1 Scores After Phase B Scores After Phase A2
No.
UL LL BM T % UL LL BM T % UL LL BM T % UL LL BM T %
1 14 7 10 31 51.6 14 8 10 32 53.3 20 13 15 48 80 20 13 15 48 80
2 10 12 10 32 53.3 10 12 10 32 53.3 18 16 16 50 83.3 18 16 16 50 83.3
3 11 18 15 44 73.3 11 18 15 44 73.3 12 18 17 47 78.3 13 19 17 49 81.6
4 11 11 17 39 65 11 11 17 39 65 17 19 18 54 90 17 19 18 54 90
5 18 18 18 54 90 18 18 18 54 90 18 20 19 57 95 19 20 19 58 96.6
6 7 11 14 32 53.3 7 12 14 33 55 8 16 15 39 65 8 17 16 41 68.3
7 3 7 10 20 33.3 3 7 13 23 38.3 4 8 17 29 48.3 4 9 17 30 50
8 0 3 9 12 20 0 3 9 12 20 1 5 11 17 28.3 1 5 11 17 28.3
X 9.2 10.9 12.9 33 54.9 9.2 11.1 13.2 33.6 56.0 12.2 14.4 16 42.6 71 12.5 14.7 16.1 43.4 72.3
SD 5.8 5.3 3.6 13.2 21.9 5.8 5.2 3.4 12.7 21.2 7.2 5.4 2.4 13.6 22.6 7.4 5.4 24 13.6 22.7
a
BM⫽basic mobility, LL⫽lower limbs, T⫽total, %⫽percentage of maximum score (60 points), UL⫽upper limbs.

100% of subjects reported a prefer- decreased significantly (P⫽.006) af- 84.69% to 94.26% (P⫽.004), only af-
ence for walking on the treadmill ter phase B compared with phase A1. ter phase B (Tab. 3).
with BWS combined with FES. The swing symmetry increased after
phases A1 and B compared with The data analysis also showed a sig-
Gait Parameters baseline and A2, respectively nificant increase in stride length after
A comparative analysis of the gait (Tab. 3), whereas the symmetry for phases A1 and B (Fig. 2B) but no
parameters is presented in Table 3, cycle length (obtained by dividing changes between phases B and A2.
which shows the means and stan- the unaffected cycle length by the Cycle duration decreased signifi-
dard deviations for all of the sub- affected cycle length and multiplying cantly after phase B, but no differ-
jects, separated into the 3 training the result by 100) increased, from ences were found when phase A1
phases. Single-limb stance duration was compared with baseline or

Table 3.
Gait Cycle Variablesa

Variable Limb Pretraining Score After A1 Score After B Score After A2


Score
Stance (s) Nonparetic 1.85⫾1.2 1.80⫾1.3 (⫺2.7) 1.66⫾1.3b (⫺7.7) 1.69⫾1.3 (⫺2.3)
Paretic 1.79⫾1.1 1.69⫾1.1 (⫺5.8) b
1.58⫾1.2 (⫺6.3) 1.60⫾1.2 (1.4)
Single-limb stance (s) Nonparetic 1.31⫾0.1 1.24⫾0.2 (⫺4.8) 1.15⫾0.2b (⫺7.3) 1.17⫾0.2 (1.4)
Paretic 1.42⫾0.1 1.26⫾0.2c (⫺11.8) 1.17⫾0.2b (⫺7.0) 1.29⫾0.1 (2.3)
c
Swing period (s) Nonparetic 0.37⫾0.14 0.43⫾0.17 (⫺17.1) 0.45⫾0.2 (⫺4.5) 0.44⫾0.1 (1.2)
Paretic 0.54⫾0.15 0.55⫾0.17 (2.2) 0.56⫾0.16 (⫺8.7) 0.53⫾0.14 (4.3)
Double-limb support (s) Nonparetic 0.91⫾1.1 0.98⫾1.2 (8.7) 0.92⫾1.2 (⫺6.8) 0.93⫾1.2 (1.8)
Paretic 0.87⫾1.2 0.98⫾1.2 (13.3) 0.92⫾1.3 (⫺6.8) 0.94⫾1.2 (1.1)
Stance symmetry (%) 89.89⫾0.1 91.44⫾0.2 (1.55) 89.34⫾0.1 (⫺2.10) 85.40⫾0.1 (⫺3.95)
c b
Swing symmetry (%) 62.07⫾0.2 71.25⫾0.2 (9.18) 78.17⫾0.2 (6.92) 66.98⫾0.2 (⫺1.19)
Cycle length symmetry (%) 89.36⫾0.1 84.69⫾0.1 (⫺4.67) 94.26⫾0.1b (9.58) 89.70⫾0.1 (⫺4.56)
a
Data are expressed as mean ⫾ standard deviation. Values in parentheses are the percent differences between the pretraining scores and the scores for
phases A1, B, and A2. No differences were found between the phase B and phase A2 measurements.
b Differences between the phase A and phase B measurements were significant at P⬍.01.
1
c
Differences between the pretraining and phase A1 measurements were significant at P⬍.01.

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Effects of Gait Training on Poststroke Gait

when phase A2 was compared with The STREAM results indicated signif- associated with repetitive move-
phase B (Fig. 2C). Gait speed in- icant benefits for the subjects. Visin- ments may induce the activation of
creased, from 0.44⫾0.06 to tin et al1 also reported change scores central pattern generators2,6 and
0.53⫾0.07 m/s, after phase B for the STREAM after 6 weeks of long-term potentiation of the motor
(P⫽.0006) (Fig. 2D). Because ca- BWS training and after a 3-month cortex, which in turn modify the ex-
dence is linearly related to gait posttraining follow-up. According to citability of specific motor neurons
speed, it also increased after phase B, Ahmed et al,29 the STREAM is pre- and facilitate motor learning.35
from 53.71⫾6.6 to 57.75⫾7.3 steps ferred over other, related impair-
per minute (P⫽.0006) (Fig. 2E). ment or disability measures for mon- According to Yan et al,36 FES induces
itoring recovery from stroke and afferent-efferent stimulation, which
Discussion focusing on the goals of immediate results in limb movement plus cuta-
In this study, we showed that 9 therapy. It can be used to monitor neous and proprioceptive inputs.
weeks of treadmill training with BWS the reemergence of voluntary move- The results of the present study re-
resulted in improvements in motor ment and basic mobility.29 The sub- vealed improvements in cycle speed,
function and in gait spatial and tem- jects recruited for this study had sig- cycle duration, and cadence during
poral variables in subjects with nificant gait disabilities, as profiled phase B. Therefore, training with FES
chronic hemiparetic stroke. How- by the clinical measures of mobility, could have activated the tibialis an-
ever, 3 weeks of treadmill training and all of them showed improve- terior muscle, leading to increased
with BWS combined with FES ments not only in spatial and tempo- contraction of the paretic tibialis an-
yielded better results with respect to ral gait variables but also in specific terior muscle and negligible co-
cycle duration, stance, and cadence components of basic mobility and contraction of the antagonist spastic
as well as cycle length symmetry. voluntary limb movements. It is plantar-flexor muscles—movements
The improvement with BWS and FES known that dynamic and static tasks that tend to occur in subjects with
was better than that obtained with are compromised after stroke, and hemiparesis. This situation could
BWS only. the results of the present study sug- have led to the significant improve-
gest that training with partial BWS ments in gait parameters during
Motor status is an important factor in and FES could change motor activi- phase B. Furthermore, training with
gait quality and gait performance in ties in both types of tasks. Although FES could be important in reminding
hemiplegia and appears to be the results of the present study are subjects how to perform a move-
strongly dependent on the degree of not conclusive in this regard, we hy- ment properly. Therefore, it is possi-
motor recovery.32 The STREAM re- pothesize that training with partial ble that FES applied to the peroneal
sults revealed considerable improve- BWS and FES also could improve the nerve facilitated motor relearning
ments in lower-limb motor function behavioral repertoire in everyday and improved ankle dorsiflexion.
and in basic mobility. The items that life, because the ability to perform
changed, especially an improvement functional activities is dependent on Previous studies with FES in subjects
in walking ability during stimulation a person’s motor ability.33,34 with chronic hemiparesis20 and
with FES, were related to gait resto- chronic spinal cord injury37 showed
ration training. Although the upper Increasing evidence has suggested that gait speed was improved after a
extremities did not undergo specific that treadmill training in older sub- training period. Pohl et al38 and Sul-
training, gait is a full-body activity; jects with hemiparesis improves livan et al39 also showed that when
that fact may account for the im- locomotor capabilities during over- trained at faster speeds, subjects
proved STREAM outcomes. Further- ground walking2 and motor relearn- with hemiparesis could effectively
more, hand control could have been ing, because it provides task-oriented improve their over-ground walking
influenced by the training, because practice of walking and active repet- speed. In the present study, we
the subjects were encouraged to itive movement training.19 It has found a statistically significant im-
hold onto the horizontal bars at- been suggested that through train- provement in this variable; however,
tached to the sides of the treadmill ing, functional movements of loco- it may not have been clinically mean-
for stability; doing so could have in- motor patterns, sensory inputs, and ingful, because although the subjects
fluenced the test results (ie, close therefore central neuronal circuits, were instructed and encouraged to
hand from fully opened position and become activated.7 In addition, in walk as fast as possible, the speed
open hand from fully closed experiments with spinalized cats and was not systematically increased dur-
position. chronic locomotor training para- ing each training session, as was
digms, it was hypothesized that pro- done in the other studies. Moreover,
prioceptive and cutaneous impulses no change in gait parameters was

September 2007 Volume 87 Number 9 Physical Therapy f 1151


Effects of Gait Training on Poststroke Gait

observed when phase B scores were subjects in the study by Hesse et al, number of people with hemiparesis
compared with phase A2 scores. This whose poststroke interval was less in rehabilitation, most were in the
result may have occurred because than 6 months. acute phase (less than 6 months after
the percentage of BWS and the tread- stroke), and the physical condition
mill speed did not change during After the gait training period, the of people with chronic stroke made
phase A2 (Tab. 1), because the sub- subjects noted an improvement in it difficult to find a larger group of
jects could not decrease BWS and their gait and balance and reported people able to take part in all phases
increase gait speed without a loss in being more able to perform their ac- of this research. Furthermore, the
gait quality. Some researchers38 have tivities in different environments. short duration of the intervention (3-
shown that speed training yields We identified 2 main advantages of week training duration) was a limita-
greater results when maximal, as op- using FES combined with treadmill tion of the study design because it
posed to submaximal, speeds are training. The first advantage was that did not allow a performance plateau
used. However, in the present study, all of the subjects reported a prefer- to be reached.
we decided to preserve good gait ence for walking on the treadmill
patterns; this strategy may explain with BWS combined with FES. They Further studies will be necessary and
the results obtained during phase A2. reported that gait training during should focus, for example, on adding
Better results might have been ob- phase B was more comfortable be- a phase B after phase A2. Doing so
tained if velocity and gait kinematics cause it was easier to place their foot would allow a comparison of the dif-
had been continually challenged dur- during early stance. The other advan- ferences between phases B and A2 in
ing training. tage was that training with FES de- subjects with chronic stroke and bet-
creased the participation of the phys- ter define the effect of training with
The stance phase for both affected ical therapists. Manual assistance FES on functional motor recovery
and unaffected limbs is greater in was provided to help the subjects and gait parameters in hemiplegia.
hemiparetic gait and represents a optimize gait quality during training, Given that the changes were as-
greater proportion of the gait cycle. and the therapists noted a decrease sessed on the day following the end
Furthermore, the stance phase on in their work. It was easier to assist of the training, it cannot be deter-
the unaffected side is greater than gait and paretic limb loading during mined with certainty whether the
that on the affected side, whereas phase B, but there was no change in intervention resulted in learning
the double-limb support phase on the number of personnel involved in (retention) or in performance
the affected side (the time spent in training with FES. adaptation.
initial double-limb support on the af-
fected side) is not greater than that It could be assumed that a simple Despite these limitations, the
on the unaffected side.40 These alter- intensity effect during phase B was present study provided important in-
ations lead to an asymmetric pattern. the cause of the improvement in gait formation about the influence of FES
The results obtained for stance phase parameters. However, different in- combined with partial BWS training
and cycle length symmetry revealed tensities cannot explain the results in subjects with chronic hemiparesis
a reduction and an increase in phase obtained, because therapy duration, and can help to optimize the physi-
B, respectively (Tab. 3), suggesting walking speed, and BWS were simi- cal therapeutic approach in stroke
an improvement in gait pattern. lar in the 3 phases. rehabilitation. In addition, this
single-case series showed an alterna-
Our motor function, cadence, and A limiting factor of the present study tive method for gait training with a
stride length outcomes are in agree- was the possibility of a carryover or treadmill and BWS that may decrease
ment with the results of the study sequence (or both) effect from one the number of personnel required to
conducted by Hesse et al,20 in which phase to the next. However, the carry out the training.
multichannel electrical stimulation A1-B-A2 design allowed for the eval-
combined with a treadmill was ap- uation of the same subject during Conclusion
plied to subjects with hemiparesis. different procedures. Furthermore, The results of the present study indi-
However, the percentage of im- this design had been chosen in pre- cate that people with chronic hemi-
provement in gait speed was very vious investigations in which sub- paretic stroke provided with training
different from our data; this differ- jects acted as their own control sub- likely would benefit from a walking
ence may be explained by the num- jects and did not limit the reliability program combining partial BWS and
ber of muscles stimulated by FES and of the studies.20,41,42 Another limita- FES. Besides the well-known effects
by the contribution of spontaneous tion was the small number of sub- of gait training with a treadmill and
recovery, particularly in 6 of the 11 jects evaluated. Despite the large partial BWS in gait restoration after

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Effects of Gait Training on Poststroke Gait

stroke, the combined use of FES ap- 6 Edgerton VR, Tillakaratne NJK, Bigbee AJ, 22 Daly JJ, Ruff RL. Feasibility of combining
et al. Plasticity of the spinal neural cir- multi-channel functional neuromuscular
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